Vaginal leucocyte counts in women with bacterial vaginosis: relation to vaginal and cervical infections

High Presence of NETotic Cells and Neutrophil Extracellular Traps in Vaginal Discharges of Women with Vaginitis: An Exploratory Study

Infectious vaginitis is a microbiological syndrome of great importance in public health that affects millions of women worldwide. However, no studies have explored the phenomenon of the production of the neutrophil extracellular traps (NETs) that are released into the female reproductive tract in these pathologies. This study aimed to determine the presence of NETosis in vaginal discharges of women with bacterial vaginosis, candidiasis, and trichomoniasis by characterizing NETs. Extracellular DNA with neutrophil elastase and citrullinated histones was identified to confirm the NET components (n = 10). The concentration, phenotypes of NETs, and number of NETotic cells were determined. The results showed an increase in NETotic cells in women with Candida albicans (CA) and Trichomonas vaginalis (TV) and an increase in NETs in TV-induced vaginitis. Samples of CA- and TV-infected women showed different NET phenotypes (diffNETs, sprNETs, and aggNETs); diffNETs were found in high concentrations in samples with CA and were increased in three types of NETs in TV infections. Samples with intermediate microbiota and bacterial vaginosis showed increased NETotic cells while the intermediate microbiota presented a higher concentration of NETs. Therefore, alterations in the microbiota and the presence of fungal and parasitic infections are important stimuli for the activation and induction of NETosis, and their cytotoxic effects could enhance tissue damage.

Torquetenovirus in pregnancy: Correlation with vaginal microbiome, metabolome and pro-inflammatory cytokines

Torquetenovirus (TTV) is a negative sense, single-stranded DNA virus present in many body fluids of apparently healthy individuals. At present, it is considered a non-pathogenic endogenous virus. TTV can be detected in the vagina of pregnant women, its abundance being modulated with the extent of immune system activation. Until now, there is only scarce information regarding the association between TTV and the composition of the vaginal environment. Therefore, this study aimed to assess the presence of TTV in the vaginal ecosystem of a cohort of white women with a normal pregnancy (n = 60) at different gestational stages (first, second and third trimester) and in 9 subjects suffering a first trimester miscarriage. For each woman, we determined (i) the presence and titer of TTV, (ii) the vaginal bacterial composition by means of Nugent score and 16S rRNA gene sequencing, (iii) the vaginal metabolic profiles through ¹H-NMR spectroscopy, and (iv) the vaginal concentration of two pro-inflammatory cytokines (IL-6 and IL-8). More than one third of women were found negative for TTV at all gestational stages. Although not statistically significant, the positivity for TTV dropped from 53.3% in the first to 36.6% in the third trimester. TTV loads varied greatly among vaginal samples, ranging between 2 × 10¹ and 2 × 10⁵ copies/reaction. No difference in TTV prevalence and loads was observed between women with normal pregnancies and miscarriages. The presence of TTV was more common in women with a higher vaginal leucocyte count (p = 0.02). The levels of IL-6 (p = 0.02), IL-8 (p = 0.03), propionate (p = 0.001) and cadaverine (p = 0.006) were significantly higher in TTV-positive samples. TTV titer was positively correlated with the concentrations of 4-hydroxyphenyllactate (p < 0.0001), isoleucine (p = 0.01) and phenylalanine (p = 0.04). TTV-positive samples were characterized by a higher relative abundance of Sneathia (p = 0.04) and Shuttleworthia (p = 0.0009). In addition, a trend toward a decrease of Lactobacillus crispatus and Lactobacillus jensenii, and an increase of Lactobacillus iners was observed for TTV-positive samples. In conclusion, we found that TTV is quite common in women with normal pregnancy outcomes, representing a possible predictor of local immune status.

Descriptive Epidemiology of Women in the Emergency Department With Gonorrhea and Chlamydial Infection in the United States

Demographic characteristics, risk factors, and clinical variables associated with gonorrhea and chlamydial infection in women being treated in emergency departments (EDs) in the United States are incompletely characterized. We used univariable and multivariable regression analyses on 17,411 encounters from women 18 years and older who presented to EDs in northeast Ohio and were tested for gonorrhea or chlamydial infection. There were 1,360 women (7.8%) who had Chlamydia trachomatis infection and 510 (2.9%) who had Neisseria gonorrhoeae infection. Those infected with C. trachomatis or N. gonorrhoeae were younger (23.8 vs. 29.2 years), unmarried (97.7% vs. 90.1%), Black (93.3% vs. 88.0%), infected with Trichomonas vaginalis (39.9% vs. 27.2%), diagnosed with urinary tract infection (15.7% vs. 10.6%), and treated for gonorrhea and chlamydial infection during the ED visit (31.6% vs. 17.4%) (all ps < .001). Women infected with C. trachomatis or N. gonorrhoeae had more urine white blood cells (WBCs) (23.9 vs. 16.4 cells per high-power field [HPF]) and leukocyte esterase (1.2+ vs. 0.8+) on urinalysis. They had more WBCs (18.5 vs. 12.4 cells/HPF) and odds of having T. vaginalis infection (12.8% vs. 8.2%) on vaginal wet preparation (all ps < .001). Women infected with C. trachomatis were more likely to be younger and not Black; they were less likely to be treated for gonorrhea and chlamydial infection in the ED and to have lower levels of urine WBCs, leukocyte esterase, and blood than those infected with N gonorrhoeae (all ps ≤ .05).

Vaginal Secretion Epithelium Count as a Prognostic Indicator of High Abundance of Ureaplasmas in Women with a Normal Nugent Score

Genital tract ureaplasma infections are associated with numerous complications, ranging from inflammation, through infertility, to problematic pregnancy. In the course of ureaplasma infection, the risk of human papillomavirus infection increases. Diagnostic tests for urea-plasma infections are not always carried out, especially in women with the normal Nugent test results. The study attempts to check whether it is possible to find a prognostic indicator that could suggest a high abundance of ureaplasmas (≥ 10⁴ CFU/ml) at the stage of the initial examination of vaginal discharge. Such a prognostic factor could qualify women for further tests to detect infections with these atypical bacteria. Six hundred twenty-seven white women with a score of 0–3 on the Nugent scale were tested, including 322 patients with a high abundance of ureaplasmas (≥ 10⁴ CFU/ml) and 305 who tested negative for these bacteria. Ureaplasma infections were detected statistically significant in women who had few or no epithelial cells in the genital swab specimens compared to the results obtained for women with numerous or very numerous epithelial cells (p < 0.001). The risk of the high density of ureaplasmas was 38.7% higher with fewer or no epithelial cells than with high numbers. In patients aged 18–40 years with few or no epithelial cells, a high density of ureaplasmas (≥ 10⁴ CFU/ml) was observed significantly more frequently (p = 0.003). Determining the number of epithelial cells in Gram-stained slides may be the prognostic indicator of ureaplasma infection. Testing for genital ureaplasma infection should be considered, especially in women of childbearing age (18–40 years), even if the Nugent test value is normal and pH ≤ 4.6.

Large-scale characterisation of the pregnancy vaginal microbiome and sialidase activity in a low-risk Chinese population

Vaginal microbiota-host interactions are linked to preterm birth (PTB), which continues to be the primary cause of global childhood mortality. Due to population size, the majority of PTB occurs in Asia, yet there have been few studies of the pregnancy vaginal microbiota in Asian populations. Here, we characterized the vaginal microbiome of 2689 pregnant Chinese women using metataxonomics and in a subset (n = 819), the relationship between vaginal microbiota composition, sialidase activity and leukocyte presence and pregnancy outcomes. Vaginal microbiota were most frequently dominated by Lactobacillus crispatus or L. iners, with the latter associated with vaginal leukocyte presence. Women with high sialidase activity were enriched for bacterial vaginosis-associated genera including Gardnerella, Atopobium and Prevotella. Vaginal microbiota composition, high sialidase activity and/or leukocyte presence was not associated with PTB risk suggesting underlying differences in the vaginal microbiota and/or host immune responses of Chinese women, possibly accounting for low PTB rates in this population.

Vaginal leukocyte counts for predicting sexually transmitted infections in the emergency department

BACKGROUND

The use of vaginal white blood cell (WBC) counts to predict sexually transmitted infections (STIs) in the emergency department (ED) is incompletely characterized.

OBJECTIVES

Our objective was to assess the relationship between vaginal wet preparation WBC counts and STIs and to determine whether WBC counts of at least 11 WBCs per high-power field (HPF) could be useful for identifying STIs in women in the ED.

METHODS

Female ED patients 18 years or older who were evaluated in a single health system between April 18, 2014, and March 7, 2017, and had a genital wet preparation WBC result were retrospectively examined using univariable and multivariable analysis.

RESULTS

Vaginal wet preparation WBC counts were examined for 17,180 patient encounters. Vaginal WBC counts of at least 11 WBCs/HPF were associated with increased odds of having gonorrhea, chlamydia, or trichomoniasis. When this threshold was used for the diagnosis of each STI, sensitivity ranged from 48.2% to 53.9%, and specificity ranged from 67.2% to 68.8%.

CONCLUSION

Women with STIs are more likely to have higher vaginal WBC counts. However, higher vaginal wet preparation WBC counts in isolation have limited diagnostic utility for gonorrhea, chlamydia, and trichomoniasis. Incorporation of age, urine leukocyte esterase results, and vaginal WBC counts provided a better predictor of an STI than vaginal WBC counts alone.

New Insights into Vaginal Environment During Pregnancy

During pregnancy, the vaginal ecosystem undergoes marked changes, including a significant enrichment with Lactobacillus spp. and profound alterations in metabolic profiles. A deep comprehension of the vaginal environment may shed light on the physiology of pregnancy and may provide novel biomarkers to identify subjects at risk of complications (e.g., miscarriage, preterm birth). In this study, we characterized the vaginal ecosystem in Caucasian women with a normal pregnancy (n = 64) at three different gestational ages (i.e., first, second and third trimester) and in subjects (n = 10) suffering a spontaneous first trimester miscarriage. We assessed the vaginal bacterial composition (Nugent score), the vaginal metabolic profiles (¹H-NMR spectroscopy) and the vaginal levels of two cytokines (IL-6 and IL-8). Throughout pregnancy, the vaginal microbiota became less diverse, being mainly dominated by lactobacilli. This shift was clearly associated with marked changes in the vaginal metabolome: over the weeks, a progressive reduction in the levels of dysbiosis-associated metabolites (e.g., biogenic amines, alcohols, propionate, acetate) was observed. At the same time, several metabolites, typically found in healthy vaginal conditions, reached the highest concentrations at the end of pregnancy (e.g., lactate, glycine, phenylalanine, leucine, isoleucine). Lower levels of glucose were an additional fingerprint of a normal vaginal environment. The vaginal levels of IL-6 and IL-8 were significantly associated with the number of vaginal leukocytes, as well as with the presence of vaginal symptoms, but not with a condition of dysbiosis. Moreover, IL-8 concentration seemed to be a good predictor of the presence of vaginal Candida spp. Cytokine concentrations were negatively correlated to lactate, serine, and glycine concentrations, whereas the levels of 4-hydroxyphenyllactate, glucose, O-acetylcholine, and choline were positively correlated with Candida vaginal loads. Finally, we found that most cases of spontaneous abortion were associated with an abnormal vaginal microbiome, with higher levels of selected metabolites in the vaginal environment (e.g., inosine, fumarate, xanthine, benzoate, ascorbate). No association with higher pro-inflammatory cytokines was found. In conclusion, our analysis provides new insights into the pathophysiology of pregnancy and highlights potential biomarkers to enable the diagnosis of early pregnancy loss.

Dual Switch in Lipid Metabolism in Cervical Epithelial Cells during Dysplasia Development Observed Using Raman Microscopy and Molecular Methods

Cellular lipid metabolism is significantly transformed during oncogenesis. To assess how dysplasia development influences lipid cellular metabolisms and what is the molecular background behind it, cervical epithelial cells of 63 patients assigned to seven groups (based on the cytological examination and HPVhr test results) were studied using a multimethodological approach including Raman microscopy and molecular methods. The consistent picture obtained studying the lipid content, cell inflammation, SREBF1 gene methylation (hence SREBP1 inhibition) and level of mitochondrial DNA copies (indirectly the number of mitochondria) showed that changes in lipid metabolism were multidirectional. Cells from patients classified as mildly dysplastic (LSIL) exhibited a unique behavior (the highest level of inflammation and SREBF1 methylation, the lowest lipid content and mitochondrial DNA). On the contrary, cells from severe dysplastic (HSIL) and cancer (SCC) groups showed the opposite characteristics including the lowest SREBF1 gene methylation as well as the highest level of mitochondrial DNA and lipid cellular concentration (for HSIL/HPVhr+ and SCC groups). Following dysplastic progression, the lipid content decreases significantly (compared to the control) for mildly abnormal cells, but then increases for HSIL/HPVhr+ and SCC groups. This intriguing dual switch in lipid metabolism (reflected also in other studied parameters) on the way from normal to squamous carcinoma cells is of potential diagnostic interest.

A case report of septic gardnerellosis

Gardnerella vaginalis is a bacterium that is found as the most common cause of bacterial vaginitis in women. In this paper, we describe a case report of a 22-years old woman infected with G. vaginalis, who was initially suspected to have Dengue fever. The similarity of clinical symptoms developed by this disease with the symptoms of some other tropical infectious diseases, as well as a travel history, complicated identification of the disease cause for this particular patient. Here, we present a detailed epidemiological and clinical description of this case, leading to a final diagnosis of a septic form of gardnerellosis.

Host-vaginal microbiota interactions in the pathogenesis of bacterial vaginosis

PURPOSE OF REVIEW

The cause of bacterial vaginosis, the most common cause of vaginal discharge in women, remains controversial. We recently published an updated conceptual model on bacterial vaginosis pathogenesis, focusing on the roles of Gardnerella vaginalis and Prevotella bivia as early colonizers and Atopobium vaginae and other bacterial vaginosis-associated bacteria (BVAB) as secondary colonizers in this infection. In this article, we extend the description of our model to include a discussion on the role of host-vaginal microbiota interactions in bacterial vaginosis pathogenesis.

RECENT FINDINGS

Although G. vaginalis and P. bivia are highly abundant in women with bacterial vaginosis, neither induce a robust inflammatory response from vaginal epithelial cells. These early colonizers may be evading the immune system while establishing the bacterial vaginosis biofilm. Secondary colonizers, including A. vaginae, Sneathia spp., and potentially other BVAB are more potent stimulators of the host-immune response to bacterial vaginosis and likely contribute to its signs and symptoms as well as its adverse outcomes.

SUMMARY

Elucidating the cause of bacterial vaginosis has important implications for diagnosis and treatment. Our current bacterial vaginosis pathogenesis model provides a framework for key elements that should be considered when designing and testing novel bacterial vaginosis diagnostics and therapeutics.

Effect of Mycoplasma hominis and cytomegalovirus infection on pregnancy outcome: A prospective study of 200 Mongolian women and their newborns

In Mongolia, diagnostic tests for the detection of the sexually transmitted mycoplasmas, ureaplasmas, Herpes simplex virus (HSV), and cytomegalovirus (CMV) are currently not routinely used in clinical settings and the frequency of these STIs are enigmatic. The prevalence of these STI pathogens were prospectively evaluated among 200 Mongolian pregnant women and their newborns and correlated with pregnancy outcome. TaqMan PCRs were used to detect bacterial and viral STI pathogens in pre-birth vaginal swabs of the pregnant women and in oral swabs of their newborns. A standardized questionnaire concerning former and present pregnancies was developed and linear regression analysis was used to correlate pathogen detection with pregnancy outcome. Ureaplasmas were the most prevalent of the tested pathogens (positive in 90.5% positive women and 47.5% newborns), followed by mycoplasmas (32.5% and 7.5%), chlamydia (14.5% and 7.5%), trichomonas (8.5% and 4.0%) and gonococcus (0.5% and 0%). CMV was found in 46.5% of the pregnant women and in 10.5% of their newborns, whereas HSV-2 was detected in only two mothers. Multiple regression analyses indicate that colonization of the mothers with U. urealyticum, M. hominis, T. vaginalis or CMV is associated with transmission to newborns and that transmission of M. hominis or CMV from Mongolian pregnant women to offspring is associated with reduced neonatal length and gestational age. Thus, diagnostic tests for their detection should be implemented in the clinical settings in Mongolia.

Cannonballs in Pap Smears: Double Whammy of Bacterial Vaginosis and Associated Infections

INTRODUCTION

Cannonballs are structures consisting of neutrophils adherent to epithelial cells, often seen in vaginal Pap smears of patients with trichomoniasis and chlamydiasis. We frequently observed these cannonballs in inflammatory Pap smears showing evidence of bacterial vaginosis.

OBJECTIVE

To study the association between cannonballs and bacterial vaginosis with associated infections in inflammatory Pap smears.

STUDY DESIGN

This was a retrospective study performed over a period of 6 months between April 2014 and September 2014. Three hundred consecutive Pap smears assessed during the study period were retrieved from the archives and studied.

RESULTS

A total of 280 smears were studied. Neutrophilic infiltrates were seen in 83.6%, cannonballs in 82.3%, and bacterial vaginosis in 70.7% of the smears. Cannonballs were found in 84.4% of the smears showing evidence of bacterial vaginosis with associated inflammatory infiltrates. There was a significant association between cannonballs and bacterial vaginosis (p = 0.0001). The odds ratio was 13.8 (95% CI: 7.2-26.2).

CONCLUSION

The present study shows a significant association between cannonballs and bacterial vaginosis and associated vaginal infections.

Sexually transmitted diseases treatment guidelines, 2015

These guidelines for the treatment of persons who have or are at risk for sexually transmitted diseases (STDs) were updated by CDC after consultation with a group of professionals knowledgeable in the field of STDs who met in Atlanta on April 30-May 2, 2013. The information in this report updates the Sexually Transmitted Diseases Treatment Guidelines, 2010 (MMWR Recomm Rep 2010;59 [No. RR-12]). These updated guidelines discuss 1) alternative treatment regimens for Neisseria gonorrhoeae; 2) the use of nucleic acid amplification tests for the diagnosis of trichomoniasis; 3) alternative treatment options for genital warts; 4) the role of Mycoplasma genitalium in urethritis/cervicitis and treatment-related implications; 5) updated HPV vaccine recommendations and counseling messages; 6) the management of persons who are transgender; 7) annual testing for hepatitis C in persons with HIV infection; 8) updated recommendations for diagnostic evaluation of urethritis; and 9) retesting to detect repeat infection. Physicians and other health-care providers can use these guidelines to assist in the prevention and treatment of STDs.

Abnormal vaginal pH and Mycoplasma genitalium infection

STUDY OBJECTIVE

Mycoplasma genitalium (MG) is a sexually transmitted pathogen linked to female morbidity, but testing for MG is not standardized. We aimed to determine which point-of-care (POC) vaginal tests could predict MG infection.

DESIGN, SETTING, PARTICIPANTS

A cross sectional study recruited sexually active adolescent women, aged 14-22 y (n = 217) from an urban medical center.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Vaginal swabs were POC tested for pH, amines, clue cells, sialidase, and Trichomonas vaginalis (TV). MG was detected by research-use-only transcription mediated amplification (TMA) assay. Presence of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) were confirmed using TMA. Three criteria were required for diagnosis of clinical BV: pH > 4.5, presence of amines, and >20% clue cells. Associations were assessed using logistic regression (LR).

RESULTS

TMA detected MG in 30 (14%), CT in 49 (23%), and NG in 21 (10%) of the samples tested. POC vaginal tests were positive for TV in 21%, amines in 52%, clue cells in 33%, sialidase in 22%, pH > 4.5 in 56%, and clinical BV in 19% of the samples tested. Using LR, pH > 4.5 was a predictor of MG (odds ratio 4.4, P < .05). Of 131 women without clinical BV or TV, 25% of those with pH > 4.5 had MG, compared to 9% of those with pH ≤ 4.5 (P = .02).

CONCLUSIONS

Until standardized, approved testing for MG is available, pH may be a useful indicator to suspect MG, especially in the absence of BV and TV.

Clinical evidence for the role of Trichomonas vaginalis in regulation of secretory leukocyte protease inhibitor in the female genital tract

BACKGROUND

Secretory leukocyte protease inhibitor (SLPI) is responsible for regulating inflammatory damage to and innate and adaptive immune responses in the vaginal mucosa. Depressed cervicovaginal SLPI levels have been correlated with both Trichomonas vaginalis infection and poor reproductive health outcomes.

METHODS

We measured levels of SLPI in 215 vaginal specimens collected from adolescent and young adult females aged 14-22 years. Log-transformed SLPI values were compared by analysis of variance or by an unpaired t test before and after adjustment for confounding effects through the propensity score method.

RESULTS

Females receiving hormonal contraceptives and those with an abnormal vaginal pH had lower SLPI levels as compared to their peers. After propensity score adjustment for race, behavioral factors, hormonal use, and other sexually transmitted infections (STIs), SLPI levels were lower in females with a positive T. vaginalis antigen test result, a vaginal pH >4.5, vaginal leukocytosis, and recurrent (vs initial) T. vaginalis infection, with the lowest levels observed in those with the highest T. vaginalis loads.

CONCLUSIONS

The SLPI level was reduced by >50% in a T. vaginalis load-dependent manner. Future research should consider whether identifying and treating females with low levels of T. vaginalis infection (before they become wet mount positive) would prevent the loss of SLPI and impaired vaginal immunity. The SLPI level could be used as a vaginal-health marker to evaluate interventions and vaginal products.

[Microbiologic basis of diagnosis and treatment of pelvic inflammatory disease]

Pelvic inflammatory disease (PID) is caused by a large spectrum of micro-organisms. However, the microbiological cause is unknown in approximately half of cases according to varying series. In the context of sexually transmitted disease (STD), the most frequently identified microorganisms causing PID are Neisseria gonorrhoeae, Chlamydia trachomatis and Mycoplasma genitalium. In such cases, bacterial vaginosis and Trichomonas vaginalis are frequently associated. In case of complicated PID or when PID is the consequence of delivery, abortion, intra-uterine procedure, bacteria that come from vaginal carriage may be encountered: Enterobacteriacae, Staphylococcus spp., Streptococcus spp., anaerobes. Mycopslama hominis as well as Ureaplasma urealyticum may also be found in this context. The microbiological diagnosis may be performed on samples of vaginal liquid, endocervix or, when available, surgical specimens. The microbiological diagnostic procedures that are used to identify these microrgansims are reviewed. Vaginal sampling may help to identify N. gonorrhoeae, C. trachomatis and M. genitalium using nucleic acid amplification tests (NAAT), and is also of interest because of the epidemiological association of PID to bacterial vaginosis and trichomoniasis. Samples from the endocervix, and if available, from endometrial biopsy surgical procedures, should be processed to detect N. gonorrhoeae, C. trachomatis and M. genitalium using NAAT, and to search for the presence of Neisseria gonorrhoeae (antibiogram should be performed), facultative anaerobes, anaerobes and capnophilic bacteria. The antibiotic treatment should at least cover N. gonorrhoeae, C. trachomatis and M. genitalium, and for most of the authors, anaerobes. In case, microbiological studies demonstrate the role of other bacteria (e.g., Enterobacteriacae), theses should be treated according to the results of antibiogram.

Cervicovaginal inflammatory cytokines and sphingomyelinase in women with and without bacterial vaginosis

INTRODUCTION

The objective is to analyze proinflammatory cytokines [interleukin-1β (IL-1β), interleukin-6 and tumor necrosis factor-α] and sphingomyelinase in women with bacterial vaginosis (BV), cervicitis and vaginitis.

METHODS

From January 2009 to June 2010, human immunodeficiency virus (HIV)-negative, nonpregnant, married women, living with husband, aged 20 to 40 years were recruited from a slum at Hyderabad, India, after taking written consent. One hundred forty-six women including 61 women with BV, 47 women with intermediate flora and 38 women with normal vaginal flora were evaluated for local proinflammatory cytokines and sphingomyelinase. Cervicitis and vaginitis were also analyzed by scoring white blood cells in the cervix and vaginal smears, respectively.

RESULTS

Of the 146 women, 50.7% had cervicitis and 19.5% had vaginitis. IL-1β, tumor necrosis factor-α and interleukin-6 levels were significantly high in women with cervicitis (P < 0.001) and vaginitis (P < 0.001) and IL-1β in BV (P < 0.005), intermediate flora (P < 0.05) when compared with normal women. High vaginal pH was associated with IL-1β. Neutral sphingomelinase showed an inverse association (P < 0.05) with cervicitis. Acid sphingomelinase directly correlated with IL-1β although not significantly.

CONCLUSIONS

This study shows proinflammatory response not only in BV but also in women with vaginitis and cervicitis. These conditions are likely to be important in promoting the transmission of HIV-1 and should be the focus of HIV prevention strategies.

Gonorrhea infection in women: prevalence, effects, screening, and management

Gonorrhea is a set of clinical conditions resulting from infection with the sexually-acquired bacterial pathogen Neisseria gonorrhoeae. Acquisition may involve multiple mucosal sites in the lower female genital tract, including the urethra, cervix, Bartholin’s and Skene’s glands, as well as the anorectal canal, pharynx, and conjunctivae. It may spread to the upper genital tract, uterine tubes, abdominal cavity, and other systemic sites. Gonorrhea is the second most commonly reported sexually-transmitted infection in the US and rates are higher among women than men. Women and infants are affected disproportionately by gonorrhea, because early infection may be asymptomatic and also because extension of infection is often associated with serious sequelae. Screening is critical for infection identification and the prevention or limitation of upper genital tract spread, and horizontal and vertical transmission. Routine genital screening is recommended annually for all sexually active women at risk for infection, including women aged < 25 years and older women with one or more of the following risks: a previous gonorrhea infection, the presence of other sexually transmitted diseases, new or multiple sex partners, inconsistent condom use, commercial sex work, drug use, or human immunodeficiency virus infection with sexual activity or pregnancy. Pharyngeal gonococcal infections are common in adolescents, and direct culture screening is necessary to identify affected individuals. Nucleic acid amplification tests (NAATs) are considered the standard for screening and diagnosis. Although urine NAAT testing is most commonly used, there is growing support for vaginal swabs collected by providers or patients themselves. Resistance to all antibiotics currently recommended for the treatment of gonorrhea has been documented and complicates therapeutic strategies. The Centers for Disease Control and Prevention recommend treatment of gonorrhea with a single class of drugs, ie, the cephalosporins.

Frequency of Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, Mycoplasma hominis and Ureaplasma species in cervical samples

We investigated the relative frequencies of Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, Mycoplasma hominis and Ureaplasma sp. in cervical samples. PCR analyses were performed in ectocervical and endocervical samples from 224 patients attending public health services in Belo Horizonte and Contagem, Minas Gerais Brazil. A high prevalence of colonisation of the cervix (6.3% for C. trachomatis, 4.0% for N. gonorrhoeae, 0.9% for M. genitalium, 21.9% for M. hominis, 38.4% for Ureaplasma sp.) was demonstrated not only for pathogens classically associated to cervicitis (C. trachomatis and N. gonorrhoeae), but also for M. hominis and Ureaplasma sp. These findings may be useful to guide more adequate diagnosis to interrupt transmission and to avoid negative impacts on the female reproductive tract.

Adolescent women can perform a point-of-care test for trichomoniasis as accurately as clinicians

OBJECTIVES

To compare the accuracy (ie, correlation, sensitivity, specificity) of self-performed point-of-care (POC) tests with clinician-performed tests for trichomoniasis in adolescent women.

METHODS

Sexually experienced women aged 14-22&emsp14;years (n=209) collected a vaginal swab and performed a POC test for trichomoniasis. Using a speculum, the clinician obtained vaginal swabs that were tested for trichomoniasis using the POC test, wet mount, culture and transcription-mediated amplification (TMA) using standard and alternative primers. Self and clinician results were compared with true positives, defined as either culture-positive or TMA-positive with both sets of primers.

RESULTS

Participants' mean age was 17.8&emsp14;years; 87% were African-American; 74% reported vaginal itching or discharge and 51 (24%) had trichomoniasis. Over 99% correctly performed and interpreted her self-test. Self and clinician POC tests were highly correlated (95.7% agreement, κ 0.87). Compared with true positives, the sensitivity of the self-POC test was 78% (CI 65% to 89%), similar to that of the clinician-POC test (84%, CI 71% to 93%) and culture (82%, CI 69% to 92%), and significantly better than wet mount (39%, CI 26% to 54%). The specificity of the self-POC test was 99% (CI 96% to 100%), similar to that of the clinician-POC test (100%, CI 98% to 100%). The sensitivity of the self-POC test was not affected by vaginal symptoms or other variables.

CONCLUSIONS

Young women performing a self-POC test detected as many trichomoniasis infections as clinician-POC tests or culture, twice as many as wet mount and slightly fewer than an amplified test. Incorporating self-obtained or self-performed POC tests into routine practice could effectively increase the identification and treatment of trichomoniasis in this vulnerable population.

Update on sexually transmitted infections, 2008

Sexually transmitted infections (STIs) continue to be a great concern in the adolescent population and of particular concern to the pediatric emergency medicine physician. The Centers for Disease Control and Prevention reports that rates of gonorrheal and chlamydial infections are greatest in female adolescents, aged 15 to 19 years, and many people acquire human papilloma virus and human immunodeficiency virus infections during their teenage years. Adolescents continue to be at a higher risk for acquiring STIs because of multiple factors, including being more biologically susceptible, more likely to engage in unprotected sex with multiple partners, as well as facing various obstacles to their use of the health care system. The pediatric emergency medicine physician must be aware of the various presentations of STIs in their patients, as well as how to adequately treat and offer counseling to this vulnerable population.

Glycerol monolaurate does not alter rhesus macaque (Macaca mulatta) vaginal lactobacilli and is safe for chronic use

Glycerol monolaurate (GML) is a fatty acid monoester that inhibits growth and exotoxin production of vaginal pathogens and cytokine production by vaginal epithelial cells. Because of these activities, and because of the importance of cytokine-mediated immune activation in human immunodeficiency virus type 1 (HIV-1) transmission to women, our laboratories are performing studies on the potential efficacy of GML as a topical microbicide to interfere with HIV-1 transmission in the simian immunodeficiency virus-rhesus macaque model. While GML is generally recognized as safe by the FDA for topical use, its safety for chronic use and effects on normal vaginal microflora in this animal model have not been evaluated. GML was therefore tested both in vitro for its effects on vaginal flora lactobacilli and in vivo as a 5% gel administered vaginally to monkeys. In vitro studies demonstrated that lactobacilli are not killed by GML; GML blocks the loss of their viability in stationary phase and does not interfere with lactic acid production. GML (5% gel) does not quantitatively alter monkey aerobic vaginal microflora compared to vehicle control gel. Lactobacilli and coagulase-negative staphylococci are the dominant vaginal aerobic microflora, with beta-hemolytic streptococci, Staphylococcus aureus, and yeasts sporadically present; gram-negative rods are not part of their vaginal flora. Colposcopy and biopsy studies indicate that GML does not alter normal mucosal integrity and does not induce inflammation; instead, GML reduces epithelial cell production of interleukin 8. The studies suggest that GML is safe for chronic use in monkeys when applied vaginally; it does not alter either mucosal microflora or integrity.

Vaginal wet mounts on asymptomatic adolescent females; are they beneficial?

BACKGROUND

Wet mounts are commonly performed at the time of pelvic exam in some settings; however, there is a paucity of data on their usefulness in asymptomatic teen patients.

OBJECTIVE

To determine if wet mounts in asymptomatic teen women are useful in detecting gonorrhea or chlamydia, when compared with DNA amplification testing.

DESIGN AND METHODS

93 consecutive charts for asymptomatic adolescent female patients seen for a routine visit were retrospectively reviewed. Data was collected for vaginal pH, presence or absence of discharge on physical exam, appearance of cervix, wet mount results, and cervical testing results. Outcome measures were wet mount findings and result of DNA amplification test on cervical sample for gonorrhea and chlamydia

RESULTS

Wet mounts were abnormal in 29 (31.2%) patients. There was no significant relationship between abnormal wet mount and positive Neisseria gonorrhoeae and Chlamydia trachomatis cultures (P = 0.083). After excluding abnormal wet mounts due to Trichomonas vaginalis, BV or Candida, all remaining patients with positive N gonorrhoeae and C trachomatis had normal wet mounts. For N gonorrhoeae, the wet mount had a sensitivity of 0% and specificity of 92.6%. For C trachomatis, the wet mount had a sensitivity of 0% and specificity of 92.1%.

CONCLUSION

Wet mounts were not useful to detect N gonorrhoeae and C trachomatis in asymptomatic teen patients. The finding of T vaginalis and BV in these asymptomatic patients may justify continuing wet mount evaluation but this practice needs further study to determine if treatment in this population will result in clinically significant effects.

Mycoplasma genitalium detected by transcription-mediated amplification is associated with Chlamydia trachomatis in adolescent women

OBJECTIVES

The clinical significance of Mycoplasma genitalium (MG) infection in adolescent women is poorly understood. We compared the prevalence of MG with that of other sexually transmitted organisms such as Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and Trichomonas vaginalis (TV) and assessed the associations of MG with sexual behaviors, genitourinary symptoms, physical and laboratory findings.

STUDY DESIGN

Women aged 14 to 21 years (n = 331) were recruited from an urban medical center. The subjects' sexual behaviors, genitourinary symptoms, and physical findings were recorded. Endocervical swabs were collected for CT and NG testing and vaginal swabs for wet mount, Gram stain, TV and MG testing. MG infection was identified by nucleic acid amplification using a transcription-mediated amplification assay.

RESULTS

MG was detected in 74 (22.4%), CT in 79 (24.4%), TV in 60 (18.2%), and NG in 35 (10.7%) subjects. MG infection was not associated with vaginal symptoms, physical evidence of cervicitis, or findings on wet mount or Gram stain. In logistic regression, variables positively associated with MG were current CT [odds ratio (OR), 2.3; 95% confidence interval (CI), 1.4-4.4] and recent sexual contact (< or =7 days) (OR, 2.0; CI, 1.1-3.2). Dysuria (OR, 0.44; CI, 0.2-0.96) and use of hormonal contraception (OR, 0.55; CI, 0.3-1.0) were negatively associated with MG infection.

CONCLUSION

In adolescent women, MG infection was as common as chlamydial infection and trichomoniasis and more common than gonorrhea. MG was associated with CT and recent sexual contact but not with vaginal symptoms or signs of cervicitis.

Cervicitis: a review

PURPOSE OF REVIEW

Sexually transmitted infections impact significantly on global health. Whereas Chlamydia, Neisseria gonorrhoea and syphilis have been extensively examined, there remains a paucity of knowledge of nonchlamydial and nongonococcal cervicitis, an arguably more prevalent but poorly characterized condition with uncertain clinical implications. With increasing application of molecular diagnostic methods for the detection of sexually transmitted infections and a growing body of literature on cervicitis, a review is timely.

RECENT FINDINGS

The number of putative aetiological agents implicated in cervicitis is growing and includes Mycoplasma genitalium, herpes simplex virus, cytomegalovirus, bacterial vaginosis and Trichomonas. The potential role of cervicitis in HIV transmission has been highlighted. Increasing broad-spectrum antibiotic usage with associated emergence of antimicrobial resistance reinforces the need for targeted antibiotic therapies, including the management of cervicitis.

SUMMARY

As our understanding of the aetiology and significance of cervicitis, particularly nonspecific cervicitis, improves, management will be refined. Advances in molecular diagnostic testing will facilitate this process, but urinary nucleic acid amplification testing should not replace clinical examination while cervicitis prevalence and significance is not yet established. A standardized approach to cervicitis research, particularly with consensus of case definition, may facilitate outcomes that can be more generally applied in clinical practice.

The future of HIV prevention: control of sexually transmitted infections and circumcision interventions

Prevention and control of sexually transmitted infections (STIs) has proven effective in reducing HIV infection when treatment is available promptly for symptomatic persons in conditions of an emerging epidemic. Biologically, it is assumed that reduced genital tract inflammation reduces infectiousness for HIV as well as reducing susceptibility in HIV-uninfected persons. Male circumcision has been demonstrated effective in reducing risk for HIV infection in three separate trials from South Africa, Kenya, and Uganda. Global expansion of STI treatment and male circumcision programs are vital tools for control of HIV infection; current evidence is reviewed and research priorities are presented.

Management of women with cervicitis

In the past several years, the collective understanding of cervicitis has extended beyond the recognition of Chlamydia trachomatis and Neisseria gonorrhoeae as the prime etiologic suspects. Trichomonas vaginalis and herpes simplex virus cause cervicitis, and both Mycoplasma genitalium and bacterial vaginosis have emerged as new candidate etiologic agents or conditions. However, major gaps in our knowledge of this common condition remain. Putative etiologic agents have not been identified in many women with cervicitis. Moreover, cervicitis occurs in a relatively small proportion of women with chlamydia or gonorrhea. Finally, scant research has addressed the clinical response of nonchlamydial and nongonococcal cervicitis to antibiotic therapy, and there are no data on the benefit of sex partner treatment for such women. New research into the etiology, immunology, and natural history of this common condition is needed, especially in view of the well-established links between cervicitis and an increased risk of upper genital tract infection and human immunodeficiency virus type 1 acquisition.

Sexually transmitted infections: screening, syndromes, and symptoms

STI are among the most common pathological conditions affecting sexually active adolescents. Both screening of asymptomatic adolescents and a thoughtful, thorough approach to the evaluation of symptoms are critical measures in STI identification and control.

Advances in diagnosing vaginitis: development of a new algorithm

The current approach to diagnosing vulvovaginal symptoms is both flawed and inadequate. Mistakes occur at the level of the patient herself, her provider, and the sensitivity of office-based tests. Often, the differential diagnosis is so broad that providers may overlook some of the possibilities. A diagnostic algorithm which separates women into either a normal or elevated vaginal pH can successfully classify most women with vaginitis. Based on the amine test, vaginal leukocytes, and vaginal parabasal cells, those with an elevated pH can be placed into further diagnostic categories. Such an algorithm helps to prioritize different diagnoses and suggest appropriate ancillary tests.

Mucopurulent Cervicitis: No Longer Ignored, but Still Misunderstood

The last decade has produced considerable advances in the diagnosis of the common etiologies of mucopurulent cervicitis (MPC), including Chlamydia trachomatis and Neisseria gonorrhoeae, and in the delineation of key aspects of their pathogenesis. Despite this, clear understanding of why these bacteria cause cervical inflammation in a minority of women who is infected with either organism is limited. Furthermore, many women who have MPC have neither of these infections detected, even when highly sensitive diagnostic tests are used. This article describes current data regarding this common condition, and charts new developments that might inform a more comprehensive understanding of MPC and its management, and of the more subtle signs of cervical inflammation that may impact women's susceptibility to a variety of infectious diseases, including HIV-1.

Bacterial vaginosis - a laboratory and clinical diagnostics enigma. Review article II

Diagnosing bacterial vaginosis (BV) has long been based on the clinical criteria of Amsel et al., whereby three of four defined criteria must be satisfied. Though there are other criteria and scoring methods which function well in comparison (i.e. Nugent scoring), it is not certain that they will always identify the same category of patients. Point-of-care methods based on various combinations of microbial products, presence of RNA, or more complex laboratory instrumentations such as sensor arrays, have also been introduced for the diagnosis of BV. No method for diagnosing BV can at present be regarded as the best. It could be that--based partly on tacit knowledge on the part of the clinical investigators scoring in the clinic--various scoring systems have been chosen to fit a particular BV-related problem in a particular population. In this review we critically examine these pertinent issues influencing clinical scoring and laboratory diagnostics of BV.